Historical Medical Policies and Clinical UM Guidelines
Historical Medical Policies
Medical policies contained within this page are historical and not the most current versions. Current medical policy content may be accessed from the Medical Policies and Clinical Utilization Management (UM) Guidelines page.
Implementation dates of the most current versions vary per state notification requirements.
- SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
- SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis
- SURG.00121 Transcatheter Heart Valve Procedures
Historical Clinical UM Guidelines
Clinical UM guidelines contained within this page are historical and not the most current versions. Current clinical UM guideline content may be accessed from the Medical Policies and Clinical Utilization Management (UM) Guidelines page.
Implementation dates of the most current versions vary per state notification requirements.
- CG-DME-42 Continuous Glucose Monitoring Devices
- CG-DME-50 Automated Insulin Delivery Systems
- CG-LAB-21 Serum Iron Testing
- CG-MED-40 External Ambulatory Cardiac Monitors
- CG-MED-68 Therapeutic Apheresis
- CG-MED-101 Home Hospice
- CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces
- CG-SURG-90 Mohs Micrographic Surgery
- CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
- CG-SURG-126 Tibial Nerve Stimulation
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